Health Questionnaire

Give us a head start on your health condition

Fill out our Health Questionnaire below to give us a head start on your current health condition. When your done, simply indicate whether you'd like us to contact you by phone or e-mail to discuss your health plan options as well as explore the possibility of scheduling you for a consultation and examination.

Health Insurance Coverage Questions?

We will gladly contact your health insurance company to determine the extent of chiropractic health coverage you have. Simply include the information in the appropriate form fields below.

Your Confidentiality Is Important To Us

Any and all information submitted is and will remain confidential.

Check any of the following SYMPTOMS that apply to you:

Back or Neck Pain, Stiffness, Soreness

Headaches

Pain between the Shoulder Blades

Muscular Spasm and Tightness

Pain, Numbness or Tingling in Arms or Legs

Chronic Pain

Painful Joints

Excess Stress

Dizziness or Loss of Balance

Low Energy and Sluggishness

Any Other SYMPTOMS you may want to discuss:

Over the LAST 12 MONTHS have you been involved in: select all that apply

Auto Injuries

Work Injuries

Sports Injuries

Other Injuries

If "Other Injury", please explain:

How has your health condition IMPACTED YOUR LIFE? i.e. prevented you from doing?